Rural general practice and ethical issues. A rapid review of the literature

S. Menezes; K. Eggleton

doi:10.1071/HC23069

RESEARCH ARTICLE (Open Access)

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Rural general practice and ethical issues. A rapid review of the literature

S. Menezes ¹ , K. Eggleton

¹ ^*

+ Author Affiliations

- Author Affiliations

¹ Department of General Practice and Primary Healthcare, Faculty of Medical and Health Sciences, The University of Auckland, Park Road, Grafton, Auckland, New Zealand.

^* Correspondence to: k.eggleton@auckland.ac.nz

Handling Editor: Tim Stokes

Journal of Primary Health Care 15(4) 366-375 https://doi.org/10.1071/HC23069

Submitted: 4 July 2023 Accepted: 11 September 2023 Published: 13 October 2023

© 2023 The Author(s) (or their employer(s)). Published by CSIRO Publishing on behalf of The Royal New Zealand College of General Practitioners. This is an open access article distributed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License (CC BY-NC-ND)

Abstract

Introduction

Key New Zealand ethical documents that describe appropriate ethical behaviour for doctors do not consider rurality and how this might impact on the practice of medicine.

Aim

The aim of this study was to understand the literature on key ethical issues experienced by general practitioners in a rural context that might inform the development of a New Zealand agenda of rural medical ethics

Methods

A rapid review was undertaken of three databases using a variety of key words relating to rurality, ethics, professionalism and medicine. Inclusion criteria were research articles focussing on the experience of doctors working in a rural healthcare setting, commentaries and narratives. The findings from the paper were synthesised and broad ethical categories created.

Results

Twelve studies were identified that met the inclusion and exclusion criteria. Synthesis of the data revealed five ethical issues that predominately arose from living and working within communities. These ethical issues related to juggling personal and professional lives, managing friendships with patients, managing loss of privacy and anonymity, assuring confidentiality and practicing outside of comfort zones.

Discussion

The majority of ethical issues arose from managing overlapping relationships. However, these overlapping relationships and roles are considered normal in rural settings. A tension is created between adhering to urban normative ethical guidelines and the reality of living in a rural environment. Professional ethical guidelines, such as those developed by the New Zealand Medical Council, do not account for this rural lived reality. Rural practitioners in New Zealand should be engaged with to progress a specific rural ethics agenda.

Keywords: general practice, medical education, medical ethics, New Zealand, rapid review, relationships, rural.

References

1 Gillon R. Medical ethics: four principles plus attention to scope. BMJ 1994; 309(6948): 184-8.
| Crossref | Google Scholar | PubMed |

2 Fors M. Potato ethics: what rural communities can teach us about healthcare. J Bioeth Inq 2023; 20: 265-77.
| Crossref | Google Scholar | PubMed |

3 Nelson W, Pomerantz A, Howard K, et al. A proposed rural healthcare ethics agenda. J Med Ethics 2007; 33(3): 136-9.
| Crossref | Google Scholar | PubMed |

4 Tricco AC, Antony J, Zarin W, et al. A scoping review of rapid review methods. BMC Med 2015; 13: 224.
| Crossref | Google Scholar | PubMed |

5 Nussbaumer-Streit B, Sommer I, Hamel C, et al. Rapid reviews methods series: guidance on team considerations, study selection, data extraction and risk of bias assessment. BMJ Evid Based Med. 2023;
| Crossref | Google Scholar |

6 Hong Q, Pluye P, Fåbregues S, et al. Mixed Methods Appraisal Tool (MMAT) Version 2018. Montreal: Department of Family Medicine, McGill University; 2018.

7 Spenny ML, Ellsbury KE. Perceptions of practice among rural family physicians—is there a gender difference. J Am Board Fam Pract 2000; 13(3): 183-7.
| Crossref | Google Scholar | PubMed |

8 Brooks KD, Eley DS, Pratt R, et al. Management of professional boundaries in rural practice. Acad Med 2012; 87(8): 1091-5.
| Crossref | Google Scholar | PubMed |

9 Phillips J, Hustedde C, Bjorkman S, et al. Rural women family physicians: strategies for successful work-life balance. Ann Fam Med 2016; 14(3): 244-51.
| Crossref | Google Scholar | PubMed |

10 Stutzman K, Ray Karpen R, Naidoo P, et al. Support for rural practice: female physicians and the life–career interface. Rural Remote Health 2020; 20(1): 5341.
| Crossref | Google Scholar | PubMed |

11 Miedema B, Easley J, Fortin P, et al. Crossing boundaries: family physicians’ struggles to protect their private lives. Can Fam Physician 2009; 55(3): 286-287.e5.
| Google Scholar | PubMed |

12 White GE, Coverdale JA, Thomson AN. Can one be a good doctor and have a sexual relationship with one’s patient. Fam Pract 1994; 11(4): 389-93.
| Crossref | Google Scholar | PubMed |

13 Chipp CL, Johnson ME, Brems C, et al. Adaptations to health care barriers as reported by rural and urban providers. J Health Care Poor Underserved 2008; 19(2): 532-49.
| Crossref | Google Scholar | PubMed |

14 Roberts LW, Johnson ME, Brems C, et al. Ethical disparities: challenges encountered by multidisciplinary providers in fulfilling ethical standards in the care of rural and minority people. J Rural Health 2007; 23 Suppl(Suppl): 89-97.
| Crossref | Google Scholar | PubMed |

15 Ullom-Minnich PD, Kallail KJ. Physicians’ strategies for safeguarding confidentiality: the influence of community and practice characteristics. J Fam Pract 1993; 37(5): 445-8.
| Google Scholar | PubMed |

16 Badger LW. Reporting of child abuse: influence of characteristics of physician, practice, and community. South Med J 1989; 82(3): 281-6.
| Crossref | Google Scholar | PubMed |

17 Senarathna L, Adams J, De Silva D, et al. Personal and professional challenges in the management of deliberate self-poisoning patients in rural Sri Lanka: a qualitative study of rural hospital doctors’ experiences and perceptions. BMC Public Health 2008; 8: 373.
| Crossref | Google Scholar | PubMed |

18 Kirchhoff AC, Hart G, Campbell EG. Rural and urban primary care physician professional beliefs and quality improvement behaviors. J Rural Health 2014; 30(3): 235-43.
| Crossref | Google Scholar |

19 Simpson C, McDonald F. In: Weisstub D, Cooley D, editors. Rethinking rural health ethics. Vol. 72. Cham, Switzerland: Springer; 2017.

20 Fors M. Geographical narcissism in psychotherapy: countermapping urban assumptions about power, space, and time. Psychoanal Psychol 2018; 35(4): 446-53.
| Crossref | Google Scholar |

21 Roberts P, Cosgrave C, Gillespie J, et al. ’Re-placing’ professional practice. Aust J Rural Health 2021; 29(2): 301-5.
| Crossref | Google Scholar | PubMed |

22 Crowden A. Virtue ethics and rural professional healthcare roles. Rural Soc 2010; 20(1): 64-75.
| Crossref | Google Scholar |

23 Rourke JT, Smith LF, Brown JB. Patients, friends, and relationship boundaries. Can Fam Physician 1993; 39: 2557-64.
| Google Scholar | PubMed |

24 Brannelly T, Boulton A, te Hiini A. A relationship between the ethics of care and Māori worldview—the place of relationality and care in Māori mental health service provision. Ethics Soc Welf 2013; 7(4): 410-22.
| Crossref | Google Scholar |

25 Mellow M. The work of rural professionals: doing the Gemeinschaft-Gesellschaft gavotte. Rural Sociol 2005; 70(1): 50-69.
| Crossref | Google Scholar |